What are the recommended management strategies for deep tissue injury (DTI) on the heel in comfort care patients?

Management of Deep Tissue Injury (DTI) on the Heel in Comfort Care Patients

For comfort care patients with heel DTI, focus on pressure relief through heel elevation/offloading and prophylactic foam dressings, while avoiding aggressive interventions that conflict with comfort-focused goals.

Primary Management Strategy

Pressure Relief and Offloading

• Implement heel elevation to completely offload pressure from the affected heel, as this is the cornerstone of DTI prevention and management 1, 2, 3
• Apply prophylactic multilayer foam dressings to the heel in conjunction with pressure relief measures, as this combination reduces heel pressure injury development 1, 3
• Ensure heels are "floating" and not resting on any surface, as sustained pressure is the primary causative factor for heel DTI 4

Wound Assessment and Monitoring

• Perform daily skin assessment to monitor DTI progression, as compliance rates exceed 96% even in patients with severe pressure injuries 2
• Document wound characteristics including size, color changes (particularly purple discoloration indicating deep tissue damage), and any evolution to open ulceration 4

Comfort-Focused Considerations

Balancing Prevention with Comfort Goals

• In comfort care patients, prioritize interventions that enhance quality of life over aggressive wound healing strategies 5
• Repositioning should be performed at intervals that balance pressure relief with patient comfort, recognizing that strict 2-hour turning schedules may not align with comfort care goals 2
• Use pressure redistribution surfaces (specialized mattresses/overlays) for patients who spend significant time in bed, as these are used in over 90% of patients with severe pressure injuries 2

Moisture Management

• Implement moisture management strategies to prevent maceration and maintain skin integrity, as these are used in 89% of patients with severe pressure injuries 2
• Keep the wound area clean and dry, using appropriate barrier products if incontinence is present 2

What to Avoid in Comfort Care

Interventions Not Aligned with Comfort Goals

• Do not pursue revascularization procedures (endovascular or surgical), as these are indicated for limb salvage in patients with goals of functional recovery, not comfort care 5
• Avoid aggressive debridement unless necrotic tissue causes discomfort or infection risk that impacts quality of life 5
• Do not apply negative pressure wound therapy, as this requires intensive management incompatible with comfort-focused care 5

Nutritional Support Considerations

• Nutritional support may be offered if consistent with patient goals and does not burden the patient, though it should not be forced if appetite is poor 2
• Recognize that nutritional optimization is typically pursued in patients with healing goals rather than comfort care 2

Dressing Selection

Recommended Dressing Types

• Use specialized heel-shaped hydrocellular foam dressings (such as Allevyn Heel) rather than traditional bandages, as these reduce pressure ulcer occurrence from 44% to 3.3% 6
• Silicone-based prophylactic dressings applied to heels reduce pressure ulcer incidence significantly (2.8% vs 10.5% without dressings) in high-risk patients 3
• Ensure dressings allow for skin inspection at least daily without requiring complete removal 6

Common Pitfalls to Avoid

• Do not assume all heel discoloration is superficial—purple heel often indicates deep tissue injury with underlying tissue damage more extensive than surface appearance suggests 4
• Avoid applying dressings so tightly that they create additional pressure points 6
• Do not neglect heel elevation even when prophylactic dressings are in place—both interventions work synergistically 1, 3
• Recognize that 31.9% of patients with severe pressure injuries do not receive heel elevation despite needing it 2

Documentation and Communication

• Clearly document the comfort care status and goals of care to ensure all team members understand the treatment approach 5
• Record daily skin assessments and any changes in DTI appearance or patient comfort level 2
• Communicate with the interdisciplinary team (nursing, palliative care, family) about realistic expectations for wound progression in comfort care 5